1. When it is required by law.2. If the patient has given consent.3. Public interest - research, education, serious crime or disease.

What life style factors promote mortality?

Describe the Health Belief Model (Becker 1974) of behavioural change.

The individual needs to believe that there are consequences and that they are susceptible to disease. They need to believe that taking action reduces the risks and that the benefits outweigh any costs.

Define ethics.

A system of moral principles and a branch of philosophy that defines what is good for individuals and society.

9

What is the Gini coefficient?

A statistical representation of a nation's income distributed among it's residents. It is the most commonly used measure of equality.

10

Responses to health inequalities: what are the main principles of the Acheson Report (1998)?

1. Reduce income inequality.2. Give high priority to the health of families with children.

11

Responses to health inequalities: what are the main principles of Proportionate Universalism?

1. Focusing only on the disadvantaged will not reduce inequalities.2. Action needs to be universal.3. A fair distribution of wealth is needed.

12

Define morality.

Concern with the distinction between good and evil or right and wrong.

13

What are Utilitarian ethics?

- An act is evaluated solely in terms of its consequences. - Maximise good and minimise harm.

14

What are the challenges/criticisms of Utilitarian ethics?

- Treats minorities unfairly to promote happiness of a majority.- Is it okay to carry out ethically questionable research to maximise the welfare of society?- What is good/better?

15

What are the main principles of Virtue ethics?

- Focuses on the person who is acting; are they expressing good character?- Integrates reason and emotion.- Virtues are acquired.- An action is virtuous only if the person is acting with the genuine intention of doing the right thing.

16

What are the challenges/criticisms of Virtue ethics?

- Virtues are culture-specific. - Too broad for practical application.- Kindness and compassion could lead to not telling the harmful truth - lying. - It is not always clear how to resolve a dilemma with virtue ethics.

What are the 4 principles of ethics?

What does the GMC say are the 5 main 'duties of a doctor'?

1. Protect and promote health.2. Provide a good standard of care.3. Recognise and work within the limits of your competence.4. Work with colleagues in a way to best serve your patients. 5. Treat patients as individuals and respect their dignity.

What can cause an ageing population?

- Improvements in sanitation, housing, nutrition and medical interventions.- Rising life expectancy.- Falls in fertility - people are having fewer children and having them later. - Decline in premature mortality.

29

What is intrinsic ageing?

A natural, universal, inevitable process.

30

What is extrinsic ageing?

Ageing dependent on external factors e.g. UV exposure, smoking etc.

31

What physical changes happen to the body later in life?

- Loss of skin elasticity and hair colour.- Decrease in size and weight.- Loss of joint flexibility.- Increased risk of illness.- Decline in learning ability and less efficient memory.

32

Why do women generally live longer than men?

- 20% biological - premenopausal women are protected from heart disease by hormones.- 80% environmental - men take more lifestyle risks than women.

33

Give 3 consequences of people living longer.

1. Pensions will have higher pay outs than currently planned.2. Chronic and comorbid conditions will prevail.3. Rising inequalities as more affluent groups will use health services for longer.

A group of minimal conditions necessary to provide adequate evidence of a causal relationship.

What could be done help to slow down the effects of climate change?

Define screening.

A process of identifying seemingly healthy individuals who may be at increased risk of a disease.

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What is the main purpose of screening?

Prevention!

63

Define primary prevention.

Preventing a disease/condition from occurring in the first place. Eliminate exposures/risk factors that contribute to the disease.

64

Define secondary prevention.

Detecting a disease as soon as possible in order to alter its course and to improve health outcomes.

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Define tertiary prevention.

Trying to slow down the progression of a disease and helping people to manage their illness effectively.

66

Define sensitivity.

The proportion of people with the disease who are correctly identified (a/a+c).

67

Define specificity.

The proportion of people without the disease who are correctly excluded by the screening test (d/b+d). How well a test detects those without a disease.

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Define positive predictive value (PPV).

The proportion of people with a positive test result who actually have the disease (a/a+b).

69

Define negative predictive value (NPV).

The proportion of people with a negative test result who do not have the disease (d/c+d).

70

Define prevalence.

The proportion of a population found to have the disease at a point in time.

71

Define incidence.

The rate at which new cases occur in a population in a certain time period.

72

What is the Wilson and Jungner criteria used for?

To determine whether a condition should be screened for.

73

What are the 10 Wilson and Jungner criteria for screening?

1. The condition should be a serious health problem. 2. The natural history of the condition should be understood. 3. There should be a detectable early stage.4. There should be a treatment available. 5. Facilities for diagnosis and treatment need to be available. 6. There should be a suitable test. 7. The test should be acceptable to the population.8. There should be an agreed policy on whom to treat.9. The cost should be balanced against the benefits.10. It should be a continuous process, not just a one off.

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Describe selection bias in regards to screening.

The people who choose to participate in screening programmes may be different from those who don't; proper randomisation is not achieved.

75

Define length-time bias.

Diseases with a longer period of presentation are more likely to be detected by screening than ones with a shorter time of presentation.

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Define lead-time bias.

Screening identifies diseases earlier and therefore gives the impression that survival is prolonged but survival time is actually unchanged.

Deliberate deviations from practices, procedures and standards or rules.

Name the 3 types of violation.

Describe skill based errors.

When performing a routine, well learnt task you may give little attention. If distracted or interrupted this can result in slips of action or memory lapses.

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Describe rule/knowledge based errors.

- When an incorrect plan or course of action is taken. This can happen in an emergency situation or can be due to a lack of experience. - Mistakes are more likely when tasks are complex. This can be due to inexperience, insufficient information, little support/advice from colleagues etc.

89

Name 5 factors that can affect performance.

1. Fatigue.2. Illness.3. Drugs or alcohol.4. Stress.5. Distraction.

90

What are the two main approaches to managing errors?

1. Person approach (individual).2. System approach (organisation).

91

Managing errors: describe the person approach.

Errors are the product of wayward mental processes e.g. inattention, distraction, negligence. It focuses on the unsafe acts of people on the front-line (nurses, doctors).

92

Managing errors: describe the system approach.

Adverse events are the product of many causal factors, the whole system is to blame (swiss cheese theory).

93

Briefly describe the Swiss cheese theory of errors.

The idea that the interaction between active failures and latent conditions leads to accidents. There are successive layers of defences and safeguards but the 'holes' can still line up and people can slip through the system.

Give 2 examples of checklists used in the NHS.

What is the SBAR checklist?

It is used for reporting a case.S - situation.B - background.A - assessment.R - recommendation.

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What is the WHO definition of health?

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

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What is the WHO definition of mental health.

Mental health is a state of well-being in which the individual realises his or her ownabilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community.

Give some examples of common mental health problems (CMHP's).

Approximately how many people worldwide have depression at any one time?

350 million.

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Approximately how many people worldwide have a severe mental illness e.g. schizophrenia?

24 million.

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What are the dangers/consequences of CMHP's?

- They have a negative impact on quality of life; effecting employment, ADL's, family. - They increase the risk of physical illness and they increase the risk of mortality from physical illness.- Depression is a major risk factor for suicide.

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What is depression?

Sustained feelings of sadness that interfere with ones ability to function at school, work and at home.

The prevalence of CMHP's is large. This results in a huge cumulative cost to society.

Name 4 interventions that can help treat CMHP's.

Interventions that can help treat CMHP's: describe community level interventions.

Focuses on strengthening protective factors e.g. school based programmes, activities for the elderly etc. Also tries to reduce risk factors e.g. social support after threatening events.

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Interventions that can help treat CMHP's: describe individual level interventions.

The patient could take medications to help e.g. anti-depressants. They could also start attending psychological therapies: CBT, counselling etc. as this follows NICE guidelines for depression/anxiety.

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Interventions that can help treat CMHP's: describe service organisation level interventions.

Management within primary care; focusing on prevention and early identification. Holistic. Encouraging self-management.

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What is IAPT?

- Improving access to psychological therapies. - The idea is to train more NHS staff in delivering evidence based CBT. - Provide support for people with CMHP's, help them get back to work and off benefits.- Psychological services can be paid for by savings made to the benefit bill.

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What is the psychological definition of stress?

Stress occurs when the demands made upon an individual are greater than their ability to cope.

Negative thoughts, no concentration, worse memory, tension headaches.

5 signs of stress: what changes occur in the emotional stage?

Define the stress-illness model.

An individuals susceptibility to disease or illness is increased because the individual is exposed to stressors which cause strain upon them, leading to psychological and physiological changes.

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What is the diagnostic criteria for PTSD?

1. The person experienced an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness, or horror.

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Give 3 symptoms of PTSD.

1. Recurrent and distressing recollections of the event(s) e.g. in dreams.2. Persistent avoidance of stimuli associated with the event. 3. Persistent symptoms of increased arousal (when the brain remains 'on-edge', wary and watchful of further threats) e.g. insomnia, irritability etc.

What aspects of behaviour can be associated with weight gain?

What developmental factors can affect a child's risk of being obese later in life?

1. Rapid infant weight gain increases the risk of obesity.2. Breast feeding is shown to decrease the risk of obesity. 3. Premature introduction of solid foods can increase the risk of obesity.4. Childhood obesity is a large predictor of adult obesity.

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What is meant by 'direct controls of meal size'?

Direct - all the factors relating to the direct contact of the food with the GI mucosa receptors.

What is meant by 'indirect controls of meal size'?

Define satiation.

What brings an eating episode to an end.

163

Define satiety.

The inter-meal period.

164

What is the satiety cascade?

Sensory -> cognitive -> post-ingestive -> post-absorptive.

165

What is the theory behind reducing the energy density of foods?

- People to tend to keep portion sizes the same regardless of the energy density of the food. - By reducing energy density we can keep the same portion sizes but consume fewer kcal and so keep satiety.

1. Variety - greater variety can lead to overeating. 2. Portion sizes have increased significantly over the last century. 3. Distractions like watching TV promote food intake. 4. Social facilitation - going out for food with friends etc.

Factors that can promote over-eating: what are examples of psychological factors?

Factors that can promote over-eating: what are examples of food-characteristics factors?

1. Macronutrient composition.2. Energy density. 3. Liquids v solids.

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What can cause an STI and how are they transmitted?

- STI's are caused by >30 different bacteria, viruses and parasites.- They are transmitted predominantly by sexual contact.

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Name the 4 main STI's.

1. Chlamydia.2. Gonorrhoea.3. Syphilis. 4. Trichomoniasis.

175

What is the 'ABC' list of HIV safety?

A - abstain. B - be faithful.C - condom use.

176

What is it important to achieve in sexual health education?

1. Involving young people effectively - they are the key decision makers. 2. Provide comprehensive and accurate information.3. Address barriers to accessing health services.4. Empower young people to make the life choices that are best for them.

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What is the definition of complementary and alternative medicine (CAM)?

A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs. Healing resources other than those intrinsic to the dominant health system of a society.

What does the NHS describe as the 'Big 5' CAM?

What is the basic economic problem with regards to health services?

1. Resources are finite (scarcity).2. The desire for services is infinite (insatiable). 3. No country can treat all treatable ill health; they don't have the capacity to do so. 4. Choice cannot be avoided (decision making).

194

What is economic efficiency with regards to health economics?

Economic efficiency is achieved when resources are allocated between activities in such a way as to maximise benefit.

195

What is economic evaluation with regards to health economics?

It is the method used to assess whether benefit is maximised - the assessment of efficiency. Are the incremental benefits of a new treatment worth the incremental costs?

How many units of alcohol can men have a day and in a week?

- 3-4 units a day.- 28 units a week.

How many units of alcohol can women have a day and in a week?

- 2-3 units a day.- 21 units a week.

222

What equation can be used to work out how many units of alcohol there are in a drink?

(%ABV x volume of drink (ml))/1,000.

223

What are the CAGE questions for alcohol dependency?

1. Have you ever fault that you should Cut down?2. Have you ever felt Annoyed by people telling you to cut down?3. Do you feel Guilty about how much you drink?4. Eye opener: ever had a drink first thing in the morning?

224

What are the social implications of alcohol?

Violence, rape, driving offences, depression, anxiety etc.

225

What are some reasons for why people smoke?

Nicotine addiction, coping with stress, habit, socialising etc.

226

Smoking laws: what law was introduced in 2005?

Smoking was banned in public places.

227

Smoking laws: what law was introduced in 2007?

The minimum age to buy tobacco products was increased to 18.

228

What is patient compliance?

The extent to which a patients behaviour coincides with medical advice. It is professionally focused and assumes that the 'doctor knows best'.

229

What are some reasons for non-compliance?

- Unintentional: forgetting or not understanding. - Intentional: the patient has their own beliefs about their condition or treatment and doesn't agree with medical advice.

A qualitative classification of data - a naming system.

What is ordinal data?

When data has numerical scores existing in order.

What is binary data?

Data that can only take one of 2 possible states. E.g. alive or dead.

What is discrete data?

Data with a finite number of values e.g. Number of people living in a house.

273

What is continuous data?

Data that can take any value e.g. height.

274

What is linear regression used for?

Estimating mean differences between groups.

275

What is logistic regression used for?

Binary outcomes. It models an odds ratio.

276

What is poisson regression used for?

It models rate ratios.

277

What is cox regression used for?

It models hazard ratios.

278

Define morbidity.

Suffering from a disease.

279

Define mortality.

The number of deaths per year for a specified disease.

280

What is the medicalisation hypothesis?

Professionals tend to see problems in terms of their own profession. Doctors therefore look at problems medically. Some conditions that seem medical can be a product of social forces e.g. mental illness can be seen medically when the route of the problem may be socially related.

281

Define iatrogenesis.

Unintended side effects caused by therapeutic intervention e.g. making someone more ill when trying to treat them.

282

Explain the concept of concordance in healthcare.

Patients are viewed as equals in care. They are involved in decision making about their treatment.

283

Behavioural change: what is the nudge theory?

Changing the environment to make healthy option an easier choice. E.g. making healthy food cheaper and more accessible.

284

If the prevalence of a disease is low, what affect does this have on false negatives?

- The number of false negatives will decrease.- NPV will increase and PPV will decrease.

285

When would a screening service look at improving the sensitivity of a test?

When the effect of missing someone with the disease and not treating them is worse than the trauma a false result will cause. The number of false negatives is minimised.

286

What is the 'prevention paradox'?

The idea that a large number of people at small risk of a disease may contribute more cases than a small number of people who are at greater risk.

287

What is the population approach to prevention?

Targeting all individuals with the aim of reducing the risk for everyone. It recognises that the low risk majority may contribute a lot of cases and it reduces social inequalities.

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What is the high risk approach to prevention?

Targeting only the individuals who are a high risk. It is accepted by society - treating those outside 'normal levels' and it is cheaper than the population approach.

289

What are the disadvantages of the high risk prevention approach?

- It favours those who are better educated: more likely to engage with NHS services and comply with treatments. - It can be difficult to identify those who are at high risk.

290

What are the disadvantages of the population approach?

- Expensive.- Public concerns over treating well people unnecessarily.

291

What is a p value?

It tells us the probability of the results being due to chance.

292

Define clinical significance.

The results are significant enough to be worthwhile clinically. They will have a genuine effect on day to day life.

293

Define statistical significance.

The results are used to accept or reject the null hypothesis. They are not necessarily clinically significant.

What are some reasons for why people start smoking?

What law was introduced in 1965 to encourage people to stop smoking?

Smoking advertisements on television were banned.

296

Describe the epidemiology of smoking.

- Married people are less likely to smoke.- Unemployed people are more likely to smoke.- There is a link between poverty and smoking; people from lower socio-economic backgrounds are more likely to smoke.

297

State two potential psychosocial implications of infertility?

1. Depression. 2. Relationship breakdown.

298

State a reason why infertility might be increasing in the general population?

People are delaying having a family until they are older. There is a higher incidence of STI's too which can lead to infertility.

299

What are the outcomes of IAPT?

Lower socio-economic groups are now more likely to access talking treatments than before. But the well-off are still paying disproportionately more for private therapy.

Give 3 barriers to improving sexual health services.

What is consequentialism (utilitarian) ethics?

An act is evaluated in terms of its consequences. Acts to maximise good.

309

What are the challenges of consequentialism?

1. Minorities may be treated unfairly to promote the happiness of the majority. 2. Determining whether a consequence is good could be subjective. 3. Is it okay to carry out ethically questionable research to maximise the welfare of society?

310

What is deontology?

Features of the act determines worthiness. Deontology teaches that acts are right or wrong, people have a duty to act accordingly. Do unto others as you would be done by.

311

Categorical imperatives are a version of deontology. What are they?

A categorical imperative is a rule that is true in all circumstances. You should act in such a way that you would be willing for it to become universal law that everyone follows in the same situation.

312

What are the challenges of deontology?

Consequences aren't looked at. Duties can conflict.

313

What are virtue ethics?

Focuses on the character of the person, integrating reason and emotion. An action is only virtuous if the person has the right mind set. Virtues are acquired.

The ability to judge well.

5 focal virtues: define integrity.

Being honest and having good moral principles.

5 focal virtues: define compassion.

Showing concern for others.

5 focal virtues: define conscientiousness.

Being thorough, careful and vigilant. Wanting to complete a job as well as you can.

319

5 focal virtues: define trustworthiness.

The ability to be relied on and trusted.

320

What are the challenges of virtue ethics?

Virtue ethics don't focus on consequences. Virtues are culture specific and too broad for practical application. It is not always clear how to solve a moral dilemma using virtue ethics.

321

What is capacity?

The patient's ability to make a decision.

322

What are the 4 questions that should be asked when assessing capacity?

1. Does the patient understand?2. Can the patient retain the information?3. Can they use the information to weigh up options and make a decision?4. Can they communicate their decision?

323

What is the age of consent for medical treatment?

16.

324

What is Gillick/Fraser competence?

If a child under 16 is assessed as Gillick/Fraser competent they can make their own decisions about their care without parental permission.

325

A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What needs to be considered when making decisions?

1. Does this patient have capacity?2. Are there any child protection issues?

326

A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What are 2 ethical problems in this case?

1. Underage sex. 2. Under 16, are they gillick competent?

327

A gentleman has made some nonspecific arrangements about his end-of-life management. His health deteriorates and the managing team consult family in making care-related decisions. According to the mental capacity act, why should family be consulted?

Family may be able to help the managing team better aware of the patient’s values and preferences when they have capacity. It can help with care-related decisions.

328

You are a medical student on a ward and you are concerned about the way one of the doctors is treating a patient. He tells you to examine the patient’s abdomen, but fails to ask for her consent. Which of the 4 ethical principles is being compromised here?

Autonomy is being compromised - the doctor is not respecting the patients decision. In this situation you would ask the patient for consent before carrying out the examination.

329

One of your fellow medical students turns up to ward rounds smelling of alcohol and you are concerned about their fitness to practice. Explain your course of action using the principle of deontology.

The duties of a doctor is a deontological document. Deontology is about the worthiness of the act. Turning up to work drunk is putting patients at risk; you are not protecting the health of patients and won't be able to provide a good standard of care.

330

You are walking home one day and a lady recognises that you are a doctor. She comes over to you and says you’ve recently been treating one of her neighbours and she wants to know how he is. She asks if you can tell her anything about his condition as she is really worried. What is your course of action?

You listen to the lady and understand her concern. However you can not tell her anything and you can not even reassure her as this would be breaking confidentiality. You could advise the lady to contact her neighbour herself and you apologise that there isn't anything you are able to say.

331

Can you think of reasons why you may not mind if the test is not particularly sensitive?

This may be acceptable where the consequences of missing the disease are minimal e.g. a disease with slow progression where delayed diagnosis was of no concern. Often screening tests with regular rounds e.g. when people are screened every 3 years have low sensitivity.

332

Why would a screening service look at improving the specificity of a test?

When the follow up diagnostic test is expensive or carries some risk so you want to minimise the number of disease free people having unnecessary procedures. Minimising False Positives may also be desirable where significant anxiety may be caused by a positive test result, or where there is significant stigma associated with the disease for which you are screening.

333

Can you think of reasons why you may not mind if the test is not particularly specific?

This may be acceptable where the condition creates little anxiety, and the follow on diagnostic testing is quick, cheap and safe.

334

What are deductive ethical arguments?

Using one general ethical theory and applying it to all medical problems.

335

What are inductive ethical arguments?

Using settled medical cases to generate theories or guides to medical practice.

336

What is the BMI range of someone who is overweight?

25-30 kg/m^2.

337

Give 2 factors in the economic environment that can lead to being overweight.

1. Unhealthy food tends to be cheaper.2. There is more advertising for unhealthy food because it is produced by large manufacturers.

338

Give 2 factors in the cultural environment for being overweight.

1. Social - eating out more. 2. Family influences - if your family eat unhealthily you're likely to as well.

339

What is the first line of treatment for obesity?

Encourage people to improve their diet and to do more exercise to lose weight.

340

Give 2 social consequences of being overweight.

1. Depression and isolation. 2. Unable to work, especially if the job is very demanding.

341

Give 2 advantages of a systematic review?

1. Can prove causation.2. Compares similar studies.

342

Give 2 disadvantages of a systematic review?

1. Time consuming. 2. Expensive.

343

Define opportunity cost.

The benefits forgone from investing and allocating resources in one thing but not in something else.

344

How do you calculate incremental cost?

New cost - old cost

345

How do you calculate the effectiveness ratio?

Incremental cost (new-old) / difference QALY (new-old).

346

What is an obesogenic environment?

An environment that encourages people to eat unhealthily and not do enough exercise.

347

Give 3 physical characteristics of an obesogenic environment.

1. Increased car culture. 2. Lifts. 3. TV remotes.

348

Give an economic characteristic of an obesogenic environment.

Expensive fruit and vegetables.

349

Give a socio-cultural characteristic of an obesogenic environment.

Family eating patterns.

350

Describe the ready, steady, stop process for quitting smoking.

- Ready: be prepared and aware, understand the process.- Steady: set a quit date, throw away ashtrays and lighters etc. - Stop: set a plan for the day, avoid triggers and reward yourself.

Give 2 reasons for an increase in childhood obesity.

Give 2 reasons for screening.

1. Identifying a disease early can improve prognosis. 2. Treatment at an early stage may be cheaper and so save money long term.3. Reduces mortality and morbidity. 4. Reassurance for those with a negative test result.

354

What is the most important statistical information you would need to give a patient who has a positive screening test result.

The PPV, the proportion of people with a positive result who do actually have the disease.